Provider Demographics
NPI:1578735676
Name:MALLON, JEFFREY C (PHARMD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:C
Last Name:MALLON
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3660 DEWEY AVE
Mailing Address - Street 2:ATTN: PHARMACY MANAGER
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-3026
Mailing Address - Country:US
Mailing Address - Phone:585-621-5600
Mailing Address - Fax:585-621-9467
Practice Address - Street 1:3660 DEWEY AVE
Practice Address - Street 2:ATTN: PHARMACY MANAGER
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-3026
Practice Address - Country:US
Practice Address - Phone:585-621-5600
Practice Address - Fax:585-621-9467
Is Sole Proprietor?:No
Enumeration Date:2008-03-28
Last Update Date:2008-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY051239183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY051239OtherPHARMACIST LICENSE